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Reviewed by Jonathan Sperber (Department of History, University of Missouri)Published on H-German (November, 2009)Commissioned by Susan R. Boettcher

Poor, Sick, and Uninsured in Germany

Ever since Otto von Bismarck took the first steps towards a state-sponsored health insurance program at the beginning of the 1880s, the German social insurance system, and public health insurance as a key component of it, has been the object of worldwide attention. Martin Krieger's work on the development of health insurance in southwestern Germany from the late nineteenth through the early twentieth century considers public and individual beliefs about health, poverty, and the role of the state in the well-being of its citizens. Particularly now, as American politicians attempt, yet again, to devise a universal health insurance scheme, a consideration of the expansion of the German system to encompass all citizens is a matter of contemporary relevance.

In contrast to the many studies of the legal and administrative basis of German social insurance, or of its broad economic effects and the large-scale challenges of its financing, Krieger's interest lies in two different areas. He attempts to elucidate the impact of the new system of health insurance at the local level, its effect on the provision of health care, particularly for the rural poor, and the way it was used by the lower classes, health-care providers, and local, county district, and provincial governments. In an investigative mode that stems, albeit rather distantly, from the ideas of Michel Foucault, Krieger also aspires to understand the historically changing self-perceptions of illness. This analysis includes the everyday practice and theoretical understanding of the nature of medicine in particular, and the effects of the gradual introduction of a universal health insurance scheme. Krieger is more successful in outlining easily understood and better-documented objective conditions--the number and qualifications of medical personnel, for instance, or the building of hospitals--than he is in elucidating the conceptually slippery and less well-documented realm of practices, perceptions, and understandings.

A regional study of the southern Rhineland, the work concentrates on four counties in the Mosel River Valley and the surrounding Eifel and Hunsrück highlands. It runs from the introduction of freedom of occupation in the medical profession in 1869 until the onset of the Great Depression and the National Socialist seizure of power in the early 1930s. The book is empirically well based, because the author made extensive investigations in local, county, regional, and provincial archives. The materials he studies have been preserved in frustratingly incomplete fashion, a challenge for the general arguments he gleans from his documents.

Perhaps the most interesting finding of the work concerns the nature of medical care for the indigent before the onset of public health insurance. The Prussian Rhineland had a crude public health care system, dating back to the Napoleonic regime, in which each rural district or Landbürgermeisterei would have a "district physician" who offered charity care to the poor. Through the 1890s, as Krieger demonstrates, these charity physicians were the only physicians resident in those rural areas. In other words, no separation was made between charity medical care and ordinary fee-for-service medical care in the countryside; the same doctor was responsible for both. The villages of the district paid their resident physician a yearly flat fee, negotiable between the local governments and the resident physicians (usually recent medical graduates, just starting their careers), that covered all their charity work. Before the introduction of Bismarck's health insurance system, the rural poor had no more difficulty in gaining access to medical care than other inhabitants of the countryside. The main problem of access to health care resulted from the need to convince physicians to live and to practice in rural areas.

In a surprising finding, Krieger observes that physicians were far from being the only, or even the most important, health care practitioners in the southern Rhenish countryside during the nineteenth century. Midwives comprised a large percentage of the health care community, providing close to blanket coverage of those areas. Their role became all the more important in the absence of doctors. Contrary to popular stereotypes, these midwives were not elderly wise women, with extensive personal experience in giving birth, but rather young women. They generally came from poor families, received six months of state-sponsored training, and worked under the (rather distant and informal) supervision of physicians and the state authorities. Far from seeing midwives as competitors, however, rural physicians supported them. Indeed, physicians constantly fought with village councils to increase the midwives' very low pay.

In a largely Catholic region, nursing was in the hands of nuns, even in Kreis Simmern, the one area Krieger investigates with a substantial Protestant population. The expansion of and increasing medicalization of nursing, as he shows, did not change this circumstance. The nursing orders began training their sisters in line with the development of scientific medicine. Lay nurses found themselves under the direction of nuns, with attendant requirements: they had to be single, young, and devoutly Catholic women. They thus followed the model of the female religious, even if not taking religious vows.

In another interesting aspect of his work, Krieger documents the considerable presence of lay healers. They operated legally, following the introduction of occupational freedom in the medical profession in the North German Confederation in 1869 (one of the more unusual but long-lasting aspects of the brief period of free-market liberalism in central Europe). These "quacks," or Kurpfuscher, as university-trained physicians called them, played an important role in medical care. The author elucidates the very diverse backgrounds of such lay healers. A few old, established, herbal specialists were among them, like the Pies family, whose members had been practicing lay healing since the sixteenth century. Most healers, though, came from two quite different sources. One consisted of individuals with training in some aspect of medicine, who then practiced it in competition with physicians. This group included midwives, but also pharmacists, former army medics, and, oddly, dental technicians. The other group hailed from the educated middle class, particularly teachers and priests, who were adherents of homeopathy. Physicians were of two minds about these healers: on the one hand, they denounced them, and tried to get the authorities to suppress them; on the other, they tacitly cooperated with them, especially when there were not enough doctors present to deal with all the sick.

Krieger suggests that the initial introduction of the health insurance system at the beginning of the 1880s did not change things much. Through the district physicians, a system of health care for the poor already more or less functioned there. Farmers and rural laborers did not have to join the health insurance scheme when it was first devised. They could adhere voluntarily, but they were grouped into separate village units, and the village itself made up any deficits between insurance premiums and costs of medical care. The existing system of district charity physicians was cheaper.

Change in the administration and provision of medical care began, somewhat haltingly, in the decade-and-a-half before the First World War. A growing number of doctors opened practices in small towns, completing the net of district physicians. Increasingly, the largest villages and towns came to have more than one resident doctor. Public health measures began to reach the countryside. These developments included disinfection campaigns and the erection of modern, medical hospitals in county towns that replaced the old-regime-style institutions, which had been combined poorhouses, nursing homes for the mentally and physically incompetent elderly, and warehouses for the chronically ill. Finally, in 1911, the agricultural population--although generally not their dependents--entered into the compulsory health insurance system. These initial developments in the Wilhelmine era grew during the Weimar Republic, when social insurance became the primary administrative node of health care for the lower classes. Meanwhile, the older institution of district charity physicians began to die out, although villages continued to provide funds for medical care of the dependents of the rural poor, who were not yet part of the public health insurance system.

The existence of multiple models created a situation in which funding for the treatment of illness could come from different sources. Here, Krieger provides an illuminating discussion of the de facto collusion between the rural poor and their village governments to shift health care costs as much as possible onto the state insurance system. The development of this system was a considerable blow to lay healers, since it did not cover their services. As a result, by the 1920s, the rural poor, previously quite eager clients of these healers, turned to them less and less. Only the educated and affluent adherents of homeopathy and other countercultural medical theories continued to use alternatives to university medicine--the origins of practices still current in Germany today.

This administrative history at the local level is thorough and quite insightful. If contemporary readers are to take any lesson from Krieger's investigations, it might be that the development of universal health insurance in Germany proceeded slowly, over a period of decades, and involved first the coexistence of previous forms of health care provision with the new public insurance scheme, and then the gradual integration of older forms of providing health care into the newer one. Of course, as is typical with regional studies, Krieger cannot speak to the possible existence of areas with different institutional arrangements, such as those lacking the Napoleonic system of district physicians. Nor can he address communities with different social structures, such as the East Elbian society of large landlords and day laborers, for instance, as compared with the southern Rhineland's many small agricultural proprietors.

Krieger's analysis of the realm of practices and mentalities suffers from some unevenness. Nonetheless, a major insight that his work provides centers on differing perceptions of the relationship between illness and poverty. The lower-class rural population understood poverty as the result of illness--seeing those parents and older children who could not work and earn money as plunging their families into misery. In contrast, physicians perceived illness as the result of poverty, poor nutrition, and, especially, the unsanitary living conditions of the rural poor.

Krieger's discussion of other aspects of mentalities and practices does not provide compelling conclusions. An obvious and classic question in the history of medicine is whether nineteenth-century physicians actually helped their patients, or if their cures made their illnesses worse. Dealing with this question seems particularly important in a work focusing on the provision of health care to the poor, since one would like to know whether access to health care actually improved poor people's health (and if so, how). Krieger evades the issue by stating that, as a non-physician, he lacks the qualifications to evaluate it. Even on less technical terrain, such as the question of whether the introduction of a social insurance system encouraged the development of an entitlement mentality among the lower classes when it came to medical care, Krieger refuses to provide a definitive answer--although his examples from the 1920s do suggest that an entitlement mentality was emerging. Questions in the Foucauldian mode, such as the social perception and the self-perception of the ill, remain unanswered. The period covered by the book saw the development of social Darwinist views of health, with an increasing emphasis on the hereditary character of illness, yet Krieger does not address even the existence of such views in the area under investigation.

This weakness may be a problem of sources, since Krieger's main material bearing on these questions are appeals of the denial of poor relief for medical purposes. To be sure, this material has only been preserved in fragmentary fashion. Yet even in areas where he does have a fair amount of material, particularly in regard to the application for poor relief for health care and the place of health care in poor relief expenditure, he elects not to draw conclusions. The few observations he does make, such as his conclusion that the rural poor balanced financial considerations with concern for their health in seeking medical care, seem to be more self-evident than surprising. The book is a very well-documented work on a significant topic. Still, its findings on the structure and financing of health care in rural areas might have been more compelling had Krieger been less cautious about making even tentative arguments based on his empirical investigations. In this sense, Krieger's preference for description over analysis makes the work an important reference study, but also limits its usefulness as an interpretative source.